Critical Access Hospitals Network April 20, 2017
ACO’s & CAH’s: Can They Co-Exist? S t eve Barnet t , DHA, CRNA April 20, 2017
Disclosures • I am a National Rural Accountable Care Consortium board member. • I am a Caravan Health board member.
Where To S tart? • We began in 2009 by implementing a Chronic Disease Registry. This act began our j ourney of understanding the population we were seeing in the Primary Care Provider (PCP) offices. • In 2010 we began elevating our awareness of the incentives built into the PGIP program with BCBS M and looked at other payer incentive programs. • In 2012 we qualified one of our PCP offices for certification as a PCMH followed by the others in 2013. • In 2012 we began evaluating ACO partner opportunities.
PGIP & PCMH • The Physician Group Incentive Program (PGIP) is a BCBS M term that rewards providers that meet clearly defined metrics. • The Patient Centered Medical Home (PCMH) model is housed under the PGIP program and also rewards providers that meet defined PCMH metrics. • We found that these activities, or any other payer like programs, were good steps to take before participating in an ACO.
Accountable Care Organization • Built into the Affordable Care Act (ACA) as a method for delivering care to an attributed population. • The intent is to help providers deliver care to the right people, at the right time, for the right reason. • To the extent that providers organized under an ACO can better coordinate care, reduce unnecessary care and prevent medical errors, quality will improve and cost will most likely go down.
ACO Choices • Pioneer ACOs were targeting organizations with experience in coordinating care across care settings. • The Medicare S hared S avings Program (MS S P) was created to coordinate care and encourage cooperation among providers for the Medicare Fee For S ervice beneficiaries. • The Advance Payment ACO Model is a MS S P that provides advance funding to smaller organizations with limited financial resources, thus allowing them to participate in an ACO.
More ACO Choices • The ACO Investment Model (AIM-ACO) builds upon lessons learned with the Advance Payment Model. • The Next Generation ACO Model allows providers to accept higher levels of financial risk and reward, than experienced in previous MS S Ps. • The Comprehensive Primary Care Plus model was introduced by CMS in 2016. CPC+ is considered an advanced Primary Care Medical Home (PCMH) model that pays for value and quality through an innovative payment structure.
What Did We Learn? • Y ou must gain support for changing how you deliver care at every level: Governance, Medical S taff, Administration, S taff, Patient. • We decided that the best way forward was to focus on improving the health of our local population. • We needed to transition how we deliver care away from sickness and volume to wellness and value. • We needed to look for programs that would compensate for those changes in care delivery.
Choose Y our Partners Wisely • We have considered a third party administrator (TP A) and an insurance company, neither worked out well. • Y our partner relationships will most likely be other organizations that deliver care and therefore bring lives to the table. • Because you will need resources to operationalize the program, your partners need to appreciate that investment in change. • Ultimately everyone needs to understand that if you don’ t perform, you may be asked to leave the island.
Demands on Management Team • Application phase was taken care of by our service partner. • While waiting for formal approval from CMS , we began identifying members and roles. • Team members represent marketing, personnel, IT , care coordination and change management. • The above described areas are broad and will be expanded upon as you begin the program. • S omeone needs to own the program; we call that person our ACO Champion.
Obstacles/ Hurdles Once Operating • Moving data! Y ou will need to move information from your electronic health record to the claims data warehouse. • Embedding a chronic care coordinator into the system can be viewed as competitive by some of your PCPs. • S ome organizations struggle with their board and medical staff adopting this change in care delivery. • I keep reminding people that we are in a schizophrenic payment period; we get paid for volume but we are trying to help people become well?
Important Competencies Developed • Learning to understand claims data and impact on care delivery. • Creating processes that identify patients who are accessing care inappropriately and begin proactively working with them. • Not letting annual wellness visits go by without getting the patient in; will lose attribution if you don’ t. • Becoming very good at coding for a more appropriate risk score of the population. • Becoming assertive with outside agencies delivering care; visiting nurses, PT , DME, etc.
Risks/ Issues Unanticipated? • We under estimated how difficult it was going to be to move EHR data to the data warehouse. • Our estimate of attributed lives was far less than we were attributed (35 – 40% ). • We expected beneficiaries to be more opposed to the program, they were actually quite receptive. • Revenue and volume has not gone down as we have worked to reduce volume?
ACO Board S tructure • We organized such that the board member is the participating organization: sometimes referred to as “ participant” or “ community.” • Typically the member CEO represents the member on the board, primarily because decisions need to be made and the CEO is already authorized to act on behalf of the member. • Physicians generally represent participants through committee assignments related to evidence based medicine adoption and focus on the most expensive chronic disorders.
Proximity, Is It Important? • Not really, in the National Rural ACO I had four partners in Northern California, two in Indiana and then two of us in Michigan. • It is important for the participants to have face to face meetings occasionally, otherwise much of the business you engage in can be done remotely. • CMS is more interested now in having ACOs that are state based because they would like to see multi-payer participation. • In Michigan we have two rural ACOs, one is pretty close while the other one is very broad as measured by distance.
Infrastructure & S upport Partner • As I described earlier, those entities that wanted to partner but had no lives were bringing infrastructure; unfortunately it was limited and expensive. • There are a number of services you may benefit from as you build your ACO, look for an entity that can provide all of those services. • Marketing, Personnel, IT , Care Coordination and maybe some assistance with change management are services you may need.
Benefits To The Organization • I think we have positively changed our culture, more of a team spirit than before. • The impression among community members is changing because they are seeing/ hearing from us when they are well, not j ust when they are sick. • Realizing the value of data, in particular claims data, and the impact it can have on how you improve care. • PQRS reporting was done under the ACO and under MACRA – MIPS is also covered; exception is Advancing Care Information that replaced MU.
Are We Happy With The Proj ect? • Y es. I’ ve found that most who engage in an ACO will not revert back to what they were doing, and this happens within the first 6 – 9 months. • Providers seem much happier working to improve health rather than j ust managing sickness. • Patients are attracted to this pro-active approach to healthcare and seem to want more. • Most payers are interested in the changes we have made and surprised we could make those changes in a short period of time.
S o Are ACOs & CAHs Compatible? • More so than most larger organizations. • Our size is our asset, nimble and flexible. • Population Health Management is all about Primary Care, Primary Care is our specialty! • I’ m certain many of you are already participating in some payer incentive program that compensates for improving health, this will take that work to the next level. • We have seen our volume go up, we believe it is because of the shift to wellness/ value; people like feeling better.
Questions?
MHA FLEX GRANT FINANCIAL REPORT REVIEW & ANALYSIS
PURPOSE • Detailed hospital-specific financial and operational assessment to identify areas of market, patient satisfaction, cost reduction, charge capture, revenue and service line opportunities.
REPORT SUMMARY • Market service area analysis • Inpatient and outpatient volume trend analysis • Market services are projected population trends • Patient satisfaction survey comparisons • Key financial health indicator trend analysis • Total revenue mark-up analysis • Cost per driver analysis for selected cost centers • Swing bed service line review • RHC benchmarking and service line review
DATA SOURCES • Most recently available public data Healthcare Cost Report Information System (HCRIS) Hospital Compare U.S. Census Bureau Medicare inpatient and outpatient claims
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